ThoracicSurgeryII

Open Chest Surgery
Outline
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A & P of descending aorta
Pathology
Diagnosis
Anesthesia
Medications
Patient preparation (positioning, prep, draping)
Equipment, Instrumentation, Supplies
Thoracotomy for descending thoracic aneurysm (groin
incision for femoral bypass)
Other Aortic Aneurysm Types (I, II, III)
PTCA
CPB
Cell Salvage
Anatomy & Physiology
of the
Thoracic Cavity
Refer to Thoracic I Lecture
Notes
Pathology
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Lungs
Carcinoma=a new growth or malignant tumor
Lung cancer #1 cause of death r/t cancer
Tumors Divided into 4 Groups:
Small Cell Carcinoma or Oat Cell (malignant)
Large Cell Carcinoma (malignant)
Adenocarcinoma (malignant)
of bronchi = primarily smokers
of bronchioles = 50%smokers
& 50%nonsmokers
Squamous Cell Carcinoma (benign) formed from
epithelial or squamous cells which line mucous
membranes)
90% malignant lung cancers r/t smoking
Pathology
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All tumor types with the exception of
small cell (oat cell), have a good
prognosis with medical and or surgical
intervention
Surgical Interventions include:
Wedge/Tumor Resection with margins
Lobectomy
Pneumonectomy
Medical Interventions include:
Chemotherapy
Radiation
Initial Diagnosis
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Cytology of sputum sample
Will determine the type of cells that
are present in the respiratory
system
Will show presence of cancer cells
but not where they actually came
from in the lungs
Most preliminary of all tests
Chest X-ray must follow to narrow
down location of tumor or mass
Initial Diagnosis
Chest X-ray
 may be found on routine exam
(asymptomatic)
 may be ordered after presents with
symptoms:
Cough
Bloody sputum (hemoptysis)
Dyspnea
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Diagnosis
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Cell type determines the course of treatment
Tumors are looked at in terms of “staging”
Staging means,” how developed is the tumor”?
Is it in the lymph nodes, has it metastasized to
another area, or is it localized
Staging is accomplished by sending a tissue sample
to pathology and having it analyzed for type
Tissue samples are obtained by biopsy
Tissue samples can be of lymph nodes or lung
tumor, done with a biopsy needle or actual wedge
resections of the lung
Biopsy can be done by bronchoscopy or
mediastinoscopy
Specimens
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Specimens must be handled
appropriately
Mishandling could damage a sample
causing it to not be analyzable
There are two types of tissue
samples in the OR related to node
or tissue:
Fresh frozen
Permanent
Specimens
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Fresh Frozen
Identifies type of tumor
Determines margins
Will entail waiting on path report
Depending on path report may be done
and close or have to reopen or proceed
Sent when tumor has not been previously
identified by mediastinoscopy,
bronchoscopy, or needle biopsy
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Permanent
Must ID the type of tumor before it
can be stained to determine staging
There are different stains required
for different types of tumors
Would send a wedge or lobe for
permanent if the tumor type had
already been Identified by a
previous biopsy (from
mediastinoscopy, bronchoscopy, or
needle biopsy)
Specimens
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Sometimes may hear “send this for
Fresh” and the doctor will want
cytology run
Cytology identifies an infectious
process:
Fungal
Bacterial
AFB (acid fast bacillus) checks for
TB
Other Diagnostic Tests for Review
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CT scan or MRI
Shows location of tumor so that if a
thoracotomy is done, the surgeon
knows where to operate to excise
the lesion
Preoperative Patient Preparation
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Chest X-ray, MRI, AND or CT Scans
should be in the OR before the patient
arrives. They May accompany the
patient. They should be displayed in the
x-ray box for the surgeon.
Type & cross should be done in the event
that the patient experiences extreme
blood loss and needs blood replacement
during surgery
These procedures are risky (large vessels
are present in the thorax & mediastinum,
and could be accidentally injured
Anesthesia
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CVP (anesthesia preference)
Arterial line
Epidural
Blood available
Medications
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NS
Sterile Water
Antibiotic in the
Irrigant
Local:
Lidocaine
Marcaine
With or without
Epi
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Bone Wax
Surgicel
Avitene
Thrombin and
Gelfoam
Focal-Seal
Other Fibrin
Sealants:
Bio-Glue
Hema-Myst
Thoracic Incisions
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Posterolateral Thoracotomy
Anterolateral Thoracotomy
Thoracoabdominal Incision
Median Sternotomy
Alternative: Transaxillary,
supraclavicular, cervical
mediastinotomy, anterior approach
Thoracotomy
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Surgical incision into the thorax or
chest wall:
Two Types:
Posterolateral Thoracotomy
Anterolateral Thoracotomy
Posterolateral Thoracotomy
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Lateral chest position for patient
Maximum exposure to lung, esophagus,
diaphragm, and descending aorta
Anterior submammary fold about nipple
level to scapular tip
May be as high as spine of scapula
For pulmonary resections (lobectomy,
pneumonectomy, wedge resection), hiatal
hernia repair, and thoracic esophagus
Anterolateral Thoracotomy
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Supine position
Support under affected side to shoulder
20 to 45° for posterior incision extension
Hips may be rotated by buttock padding
Submammary incision just below breast
from anterior midline to mid or posterior
axillary line
Access at fourth intercostal space
For pulmonary cyst or localized lesion
resection or open lung biopsy
Thoracoabdominal Incision
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Lateral position
Incision from posterior axillary line to
abdominal midline
7th or 8th intercostal space
Exposure to upper abdomen,
retroperitoneal area, and lower chest
Repair of hiatal hernia, esophagectomy,
espophagogastrectomy, retroperitoneal
tumors, and thoracic aneurysm resection
Factors Influencing Thoracic Incision
Location
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Exposure
Physiologic intrapleural pressure changes
Chest movement
Maintenance of chest wall integrity and
diaphragm
Lung and underlying pleura condition
Minimizing invasiveness of procedure
Patient Positioning
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Posterolateral
Operative side up
Beanbag (surgeon preference) under drawsheet
Pillow under head
Upper arm on padded mayo
Lower arm on padded armboard
Axillary roll (protect brachial plexus)
Padding under bottom leg
Pillows between legs (peroneal nerve) and feet
Safety strap and tape across mid pelvic area
Lower body Bair hugger sheet, cover with blanket
Prep
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Towel drape over epidural catheter
Base of neck to hips and side to
side to bed
Begin at incision site work around in
circle, prepping axilla last
Usually betadine soap followed by
betadine paint
Draping
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Towels x 4 or five
Drying towels
Ioban
Universal sheet or laparotomy sheet
Equipment
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ECU
Suction x 2 (1 for surgery & 1 for
beanbag)
Bair Hugger
Bronchoscopy Cart
Stapler Cart
Instrumentation
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CV or Major Tray
Chest Tray
Chest Retractor of Surgeon Choice
(Finochettio, Tuffier, Burford)
Extra long instrument tray
Doctor specials
Long medium and large clip appliers
Chest Tray Instruments
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Bronchus clamps
Duval Lung clamps
Allison lung retractor (whisk)
Davidson scapular retractor
Doyan raspatories (pigtails) right & left
Elevators (Cameron, Alexander,
periostial, other)
Box cutter, Bethune rib shears, Guillotine
Bailey rib approximator
Supplies
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Basic or Cardiovascular pack
Minor or Major basin set
Transverse Laparotomy or Universal drape pack
Gowns, Gloves, Towels
Chest tubes (various are surgeon preference)
Clip cartridges
Suture (prolene, silk, heavy fascia/muscle layer
suture, vicryl, other nonabsorbable, skin suture)
For chest tubes, cutting needles with heavy silk
ties
Magnetic pad/drape
Bovie with extension
Suction tubing, yankaur tip, cell saver (optional)
Supplies Continued
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Kittners
Raytex for sponge sticks
Laparotomy sponges
Long umbilical tapes
Thoracotomy with Lobectomy or
Pneumonectomy (Procedure)
Incision made with #10 or #20 blade on #3 knife handle
(made at 4th intercostal space for UL/5th or 6th for ML or LL)
 Cautery used to bovie bleeders and open the fascia and
muscle layer
 Surgeon will used his hand to loosen fascia
 Surgeon assistant will hold a scapular retractor so surgeon
can free up entire area
 May want forceps (debakeys) and cautery or metz to open
muscle layer
 If removing a rib will use periosteal elevator such as a
cameron or alexanders to scrape away fascia and cartilage
from rib
 Will use doyan pigtail to completely free rib
 Will cut rib at either end to remove it with a guillotine or
rib shear
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Thoracotomy with Lobectomy or
Pneumonectomy (Procedure)
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Self-retaining retractor of choice is placed after
rib removal
If does not remove a rib will place self-retaining
retractor of choice
May use a burford (short or long blades or one of
each) or tuffier or finochettio
Once retractor is in, will change bovie tip to long
extention tip and give the surgeon and his
assistant long debakeys (may want extra long
debakeys/have extra long instrument set
available)
Will begin dissection of lobe to be removed or
entire lung
Thoracotomy with Lobectomy or
Pneumonectomy (Procedure)
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Will use right angle and 0 silk ties to tie off vein
and arteriole branches, as well as long medium
and large clips
May also request silk or prolene suture on a 3-0
or 4-0 taper needle
Will dissect with long metz alternating with the
cautery, debakeys and a long kittner on a long
kelly
May request lung retractor (whisk or egg-beater)
and or a sponge on a stick to the assistant for
exposure
Will request one or two lovelace lung clamps
when ready to staple bronchi or lobe tissue
Staplers used for Lobectomies and
Pneumonectomies
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Linear staplers (old name GIA)
Come in 55mm and 75mm
May want bovine pericardial or synthetic peri-strips
applied to stapler (used to reinforce suture line made
by the stapler)
Thoracotomy staplers (are U-shaped)
Come in 35mm, 60mm, and 90mm staple line length
35mm and 60mm may be 3.5mm (blue) or 4.8mm
(green) staple width and have reloads in those sizes
White staple reloads are thicker than the blue or green
35mm also come in a vascular style (red) for bronchi
Manufacturers recommend a new stapler be used after
reloading three times (This is often not done for cost
saving reasons)
Thoracotomy with Lobectomy or
Pneumonectomy (Procedure)
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Once a stapler is fired a 15 blade on a long #3
knife handle will be used to free the tissue from
the staple line
Several stapler applications may be needed
Once the wedge, lobe or lung is removed the
chest cavity will be irrigated with warm NS or
Water using an asepto or cytal pitcher and suction
Irrigant will be left in momentarily to determine
air leaks in the suture line (there will be bubbling)
Repair suture may be needed (silk or prolene)
Hemostatic or synthetic sealant agents may be
used
Irrigation
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NS is used when there is no cancer
Water is used if there is cancer present
Water causes lyses of cancer cells, which
can allow those cells to be suctioned out
of thorax
NS could lead to metastasis or spreading
of the cancer cells to other areas if those
cells that are present are not lysed and
suctioned out
These patients often will receive radiation
or chemotherapy post-hospitalization
Specimen
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If a lobe or wedge is removed, it will be sent for
frozen with margins
Clarify specimen type and what the specimen is
with the surgeon
NEVER pass off lung tissue or lymph nodes
to go in formaldehyde (permanent
specimen) unless CERTAIN that is what
surgeon wants!
Ask before you pass it off
Waiting will be involved to determine if margins
are clear
If margins are not clear, you will go back and
remove more lung tissue
Thoracotomy with Lobectomy or
Pneumonectomy (Procedure)
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Once the irrigant is suctioned out, chest tubes of the
surgeon’s choice will be placed using a 10 blade on a
#3 knife handle (incisions are made below the
thoracotomy incision), cautery may be used, a tonsil or
kelly will be used to pass the chest tube through the
chest wall for placement in the thoracic cavity
These will be sewn in using a large cutting eyed-needle
with a #1 silk tie for each chest tube inserted
These should be cut for approximately 5 inches of
length, a Y connector inserted for two, and hooked up
to the pleurevac
Pleurevac should be filled with NS to appropriate level
Chest tubes must be secured with tape or plastic tie
bands
Pleurevacs
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Pleurevacs (water seal drainage with
suction)
Pneumovac or pneumonectomy pleurevac
(pressure control chambers/NO suction)
Pneumonectomy pleurevacs are used only
for pneumonectomies
May not use any chest tubes with a
pneumonectomy
Regular pleurevacs are used for chest
drainage for all other chest procedures
Thoracotomy with Lobectomy or
Pneumonectomy (Procedure)
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Pericostal closure of the thoracotomy
incision will begin with one or two bailey
rib approximators for rib reapproximation
Heavy (#1) absorbable suture (vicryl,
dexon, or PDS) on a CTX or TP-1 taper
needle for intercostal muscle closure
These are usually interrupted sutures
(have mayo scissors ready to cut and
hemostats)
They are usually placed, needle cut, and
tagged with a hemostat
They are tied after they are all placed
Thoracotomy with Lobectomy or
Pneumonectomy (Procedure)
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Remaining muscle/fascia will be closed with a
running #1 PDS or Vicryl on a CTX taper needle
Subcutaneous tissue will be closed with a 2-0 or 0
Vicryl on a CT-1 or CTX tapered needle
Subcuticular layer will be with 4-0 Vicryl or
Monocryl on a PS-1 cutting needle
Skin staples may be used in some institutions
Dressing is drain sponges or 4x4s for the chest
tubes, telfa, 4x4s, and Primapore
Other dressing choices may be used
Watch when patient is being moved to make
certain that chest tubes are clear and not pulled
out!
Descending Thoracic Aneurysm
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Anatomy and Physiology of
Thoracic Aorta
Thoracic aorta extends to the
diaphragm
Thoracic aorta supplies chest wall,
diaphragm, esophagus, bronchus,
and the spinal cord
Aneurysm
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Localized abnormal dilation of an
artery resulting in pressure of the
blood on the vessel wall that has
been weakened
Pathology of Aneurysms
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Develop at sites of arterial weakness
Causes: 1. Atherosclerosis 1° cause
2. Congenital weakness
Marfan’s syndrome
Ehlers Danlos syndrome
(both are hereditary disorders that affect
the elastic connective tissues which lead
to weakening or thinning of the aorta)
3. Acquired
Trauma
Aneurysms
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1.
2.
3.
Three types:
True-arterial wall weakness aneurysmal
sac involves one or all layers of the
arterial wall
False-results from trauma, causes
leakage into a layer of the arterial wall
creating a blood clot or hematoma
Dissecting-as intima of artery tears,
blood escapes which can lead to
hemorrhage and sudden death
Thoracic Aneurysm
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Origin point at or below the left
subclavian artery
Depending on extensiveness of
aneurysm, can be operative or
inoperable
Most frequent complication is
paralysis
Diagnosis
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Majority are Asymptomatic until they become
enlarged
Discovered on routine chest x-rays
Routine physicals when an abdominal bruit is
auscultated or a pulsatile mass is palpable
Symptoms include neck, chest, lower back,
abdominal, or flank pain that extends to the groin
Depending on aneurysm involvement can cause
symptoms associated with structures supplied
with blood at that section of the aorta
Diagnostics/Preoperative Testing
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Confirmed with:
Ultrasound
CT
MRI
Aortograms
Anesthesia
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Arterial line
Swan ganz catheter
NG tube
TEE to check placement of bypass
cannuli (some places may use CArm)
Epidural Catheter
BLOOD available (may want in
room)
Medications
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NS irrigation with antibiotic of
choice
Topical hemostatic agents of choice
Patient Preparation and Positioning
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Shave is anterior and posterior,
including anterior thorax, abdomen,
bilateral groins, to knees, and the
back
Prep is betadine soap (x 10 minutes
if time permits) and betadine paint
Position is Left Posterolateral or
thoracoabdominal
Posterior Lateral Position
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Headrest
Axillary roll (prevent brachial plexus injury)
Beanbag (on bed before patient) with suction)
Padded armboard for lower arm
Padded mayo for upper arm or airplane arm sling
Padding under lower leg and pillows between
knees and feet
Will expose left groin by slightly frog legging left
leg
Draping
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Towel Drape over epidural catheter
Towels for perimeter of surgical site
Drying towels
Ioban Drape
Universal Drapes or CV Drape
(will expose left groin)
Equipment
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Bair hugger (lower body)
Cell saver
Bovie
Extra suction
Beanbag
Defibrillator
Bypass machine (partial bypass usually
employed)
Saline Warmer
Cryothermia Unit (available) surgeon
choice
Instrumentation
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Chest tray
Cardiovascular tray or Major Tray
Aortic clamps (surgeon choice)
Open Heart tray
Long medium and large clip appliers
Extra long instruments
Tube holder, allis, or edna clamps to
secure bypass tubing
Chest Retractor of surgeon choice
Internal Defibrillator Paddles (external
available) BOTH STERILE
Supplies
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Cautery
Open heart specialty tray
Major Basin Tray
Magnetic Drape
Miscellaneous prolene suture
Miscellaneous silk ties
Cutting free needles
Straight Woven Dacron Grafts (Miscellaneous sizes)
Femoral arterial and venous cannuli
Tourniquet snares or rommels
Vessel loops or umbilical tapes
Warm NS with antibiotic of choice
Heparinized saline
Topical hemostatic agents
Chest tubes
Procedure
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Left groin exposure for atrial to femoral bypass by
centrifugal pump for lower aortic vessel perfusion
Scalpel
Metz/cautery
Weitlander
Right angle
Vessel loops or umbilical tapes
Rommel or tourniquets (if using 18F robnel catheters will
have cut short about three inches long during your set-up)
Patient is heparinized
Peripheral debakeys x 2
11 blade for arteriotomy, arterial cannula, tubing clamps (one
for arterial cannula one will be on pump tubing)
Care is taken to NOT introduce air to line, may fill with NS
slowly
Procedure
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Vascular clamp or tonsils x 2 may
be used to grab femoral vein, 11
blade venous cannula, tubing
clamps (same as arterial sequence)
May secure cannuli with heavy silk
sutures on cutting needles to
patient’s skin
Procedure
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Thoracotomy
Incision made with #10 or #20 blade on #3 knife handle
Cautery used to bovie bleeders and open the fascia and
muscle layer
Surgeon will used his hand to loosen fascia
Surgeon assistant will hold a scapular retractor so surgeon
can free up entire area
May want forceps (debakeys) and cautery or metz to open
muscle layer
If removing a rib will use periosteal elevator such as a
cameron or alexander to scrape away fascia and cartilage
from rib
Will use doyan pigtail to completely free rib
Will cut rib at either end to remove it with a guillotine or
rib shear
Procedure
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Place chest retractor of surgeon choice
Dissect to aorta
May isolate with a long polyester tape or 1”
penrose and clamp with a kelly
Will measure aorta to determine graft size needed
Obtain graft requested
Surgeon may request more heparin be given
Aorta is cross clamped with aortic clamps x 2
Aortic arteriotomy made with blade of choice on
long knife handle
Aneurysm tissue and clot are removed
Procedure
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Graft will be sewn in with prolene suture (should
have what surgeon uses ready to go (this is a
surgery where time is of the essence, you will be
MOVING) proximal end then distal end
Clamps are removed, proximal first
Suture will be tied down after removal of clamp to
allow aorta to vent (avoids air being left in aorta)
Surgeon may want his hands wet to tie
Protamine is given and patient is taken off bypass
when stabilized
Have peripheral debakey clamps and tubing
clamps ready, as well as prolene suture to close
femoral artery and vein of surgeon choice
Procedure
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Irrigation of wounds
Femoral incision packed temporarily with
antibiotic soaked raytex until closed
Chest tube placement with anchor sutures
Suction them out before connecting to
Pleurevac
Chest will be closed as per thoracotomy
incisions (periostium, muscles, fascia,
subcutaneous, subcuticular)
Groin will be closed
Dressings per surgeon choice
Other Aortic Aneurysms
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Type I
Type II
Type III
Discussion
Coronary Angioplasty (PTCA)
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Discussion
Cell Salvage by Cell Saver
Cell Salvage
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Blood recovered during surgery and
reinfused
Is directly suctioned, filtered,
anticoagulated, and reinfused with
little RBC damage
May be aspirated directly or via
squeezed out sponges into a basin
Contraindications for Cell Saver
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No hemostatics-may clot blood
rendering it useless
Certain antibiotics (ex. Bacitracin)
may lyse cells, damaging them
No exposure to gastric contents,
amniotic fluid, or fluid potentially
containing cancerous cells
No local or systemic infection
Cardiopulmonary Bypass
Cardiopulmonary Bypass (CPB)
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Method used to divert blood from the
heart and lungs to provide a stationary
bloodless field and optimal organ tissue
function during heart surgeries
OPCAB (off pump coronary artery bypass)
heart is beating and bleeding; visibility
challenging; preferred for patient’s at risk
of complications from CPB; must be to be
ready to go on bypass if the patient
cannot tolerate CABG procedure without
having an arrested heart
CPB Process
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Blood is removed from the right atrium
via the inferior vena cava
Can be accomplished using inferior vena
cava cannulation alone or with both SVC
and IVC cannulation called bi-caval
cannulation
Is routed to the CPB machine for
oxygenation
Blood is returned via the aortic cannula or
femoral arterial cannula to provide
oxygenated blood to the patient’s body
CPB Machine Components





Oxygenator-removes carbon dioxide and
delivers oxygen
Heat exchange coil-can heat or cool the
blood
Pump-moves the blood
Filters-removes particulate, air,
microemboli
Sensors-detect air bubbles, low oxygen
saturation, and low blood volume
collection
CPB Continued


Heparin is given intravenously for
anticoagulation
Cannuli and CPB circuits may also
be heparin-bonded
CPB Perfusionist

1.
2.
3.
Control many physiologic variables
along with anesthesia and the
surgeon:
Hemodilution ↓ blood viscosity =↓clot
HCT ↓ = ↓ clotting
Hypothermia = ↓ cellular oxygen
consumption/demand = ↓ chance of organ
damage
Core temperature is ↓ from 28 to 30° C
Summary






A & P of descending aorta
Pathology
Diagnosis
Patient preparation (positioning, prep,
draping)
Equipment, Instrumentation, Supplies
Thoracotomy for descending thoracic
aneurysm (groin incision for femoral
bypass)
Summary Continued




Other Aortic Aneurysm Types (I, II,
III)
PTCA
CPB
Cell Salvage